Contact Us - 2007 Diabetes Walkathon Registration

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2007 Diabetes Walkathon Registration

Register Today!
One person per registration form please. You can either register here on line or print out registration * and mail to North Country Hospital's Development Office, 189 Prouty Drive, Newport, VT 05855

I am walking as:

Individual	Team member
Team name:
Team Captain Name:

First Name:

Last Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

E-mail:

T-Shirt Size:

Start your fundraising by making a personal donation. Enter the amount you would like to give:

In Memory of:

In Honor of:

Method of Payment:
Send check made payable to:
North Country Hospital Diabetes Education
189 Prouty Drive, Newport, VT 05855 or online by credit cards, with PayPal after submitting this form.

How did you hear about the 2007 Diabetes Walkathon for North Country Hospital?
Newspaper article or ads
Radio
Poster
E-Mail
Word of mouth
Other

I am a diabetic I have a family member who is/was a diabetic
I know someone with diabetes

Waiver of Liability

In consideration of being permitted to participate in the “2007 Diabetes Walkathon“, I, for my self, my heirs, personal representatives or assigns, do hereby release, waive, discharge North Country Health System, its officers, employees, and agents from liability from any and all claims resulting in personal injury, accidents, or illnesses and property loss arising from, but not limited to, participation in the September 16, 2007 Walkathon.

Initials of Participant:

Name of Participant:

Date: Age (if minor):

Initials of Guardian:

Name of Guardian: Date:

Pledge sheet

* Free Adobe Reader required